SPOUSE OR PARTNER CONTACT INFORMATION [If applicable]
EMERGENCY CONTACT INFORMATION:
Height: feet* feet inches* inches
Weight: lbs* lbs
PERSONAL MEDICAL HISTORY:
Assignment & Release
I First Name* Last Name* assign directly to Dr. David P. Rapaport and associates all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges incurred. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.
David P. Rapaport, M.D., & associates feels strongly about his patients' privacy as well as his practices' right to control its public image and privacy. David Rapaport, M.D., and associates agrees not to be paid for selling patients lists or protected health information to any third party for the purpose of marketing directly to his patients. In consideration for treatment and the above noted Patient protection, Patient agrees to refrain from directly or indirectly publishing or airing commentary upon the Physician; and they will use all reasonable efforts to prevent any member of their family from engaging in such activity. David Rapaport, M.D., and associates has the right to equitable relief to prevent the initiation or continuation of publishing or airing of commentary upon his practice, expertise and/or treatment. Both Physician and Patient will work to prevent the publishing or airing of commentary about the other party from being accessed via internet, blogs or other electronic, print or broadcast media without prior written consent. Finally, this Agreement shall be in force and enforceable for a period of five years from Physician's last date of service to Patient. Patient has been given the opportunity to ask questions and receive adequate answers to his/her satisfaction. Refund policy: Please note that our office does not provide refunds on any services rendered. All sales, including deposits for treatments, are final. Skincare products may be exchanged if damaged or unused within 14 days of purchase.
As a courtesy to our providers and patients, we require at least 2 business days’ notice for cancelling or rescheduling appointments. Missed, rescheduled, or cancelled appointments without 2 business days' notice will incur a no-show fee of $100.
All appointments require a credit card on file including complimentary appointments and services intended to be paid for with a gift card.
Some of our services require a scheduling deposit at time of booking. Scheduling deposits are applied towards your scheduled treatment. If you need to cancel or reschedule your treatment and provide adequate notice of 2 or more business days, we will credit your account the scheduling deposit we collected as a credit towards future treatments. The scheduling deposit is nonrefundable.
To avoid the no show/cancellation fee of $100 please make sure you reach out to us at least 2 business days prior to your scheduled appointment.
Please note that we do not accept third party financing for appointment deposits. Scheduling deposits and payments for procedures are non-refundable.
Consultations with Dr. David P. Rapaport are $500, due 2 business days prior to the scheduled appointment. The consultation fee is non-refundable. Your consultation fee is applicable to your quote for up to one year from the date of issuance. Missed appointments, or appointments cancelled without 2 business days' notice, will incur a fee of $250.
Dr. Mansher Singh offers complimentary consultations. However, please note that a valid credit card is required to schedule your appointment. We require 2 business days’ notice prior to your scheduled appointment to avoid the no show/cancellation fee of $100.
Prior to your appointment, you will receive an email and/or text message prompting you to confirm your booking. Should you need to cancel or reschedule before the cancellation period, please call the office. If a response has not been received by two business days ahead of your appointment, we will make a courtesy call or send another message to request your confirmation status. If your reservation remains unconfirmed 2 business days in advance of your appointment, your reservation will be canceled.
I authorize Coolspa, David P. Rapaport, M.D., F.A.C.S., and any of its Associates/Providers to keep my credit card information on file and to charge this card for any outstanding balances.
My signature below indicates I have read, understand, and agree to the terms stated in this agreement.